Basic Information
| Provider Information | |||||||||
| NPI: | 1255731550 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HATALLA | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100A HAVERHILL ST | ||||||||
| Address2: | |||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018444251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786825276 | ||||||||
| FaxNumber: | 7818480206 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W CUMMINGS PARK | ||||||||
| Address2: | |||||||||
| City: | WOBURN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018016503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7819320970 | ||||||||
| FaxNumber: | 7819320218 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2014 | ||||||||
| LastUpdateDate: | 10/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 10574 | MA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10574 | 05 | MA | MEDICAID |